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BACKWATER PREVENTION DEVICE FINAL <br /> Q, INSTALLATION CHECKLIST <br /> t'►'lE.�{`i can �� �G ^� �� e-��-7�'� L LG <br /> Instaliation Company Name and CoNaet In(o:.S�C.0 ` P �1 �,1•�-��5%�n�i r'rJi �':K,Z'��ID • ,�?Usf;� <br /> Dale Backwater Prevention device(�WD)�vas insialled: � -3'��! Date this form�vas compieted: �/�3�I S <br /> Installation Property Owner Name and Contact Info: ��c;C�AQ�+ /7� �'�'t'f�� `��35��`�b''�� <br /> ProperlyAddress: 1�O( (•e1PIfG14ore- iy�le. , �r/P�� Akao1 <br /> Pre-Instailation Inspection Cheeklist: <br /> All ilems must be checked'Yes'in order for a BWD l0 6e considered for insf�llation <br /> Is ihere a basement or level of the house ihat is at or near assumed sewer main elevation7 �Yes ❑ No <br /> Are lhere fixtures in lhe house located below the upslream sevaer manhole rim elevation? Q Yes ❑ No <br /> Is fhe side sewer currenfly UNPROTECTED froin sewer backups(does not have a BWD installed)? 0 Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e chedced'Yes'be(ore inspection is conside;ed complete ,, <br /> , <br /> Was side sewer TV inspected from buildinc�do sewer main7 m Yes ❑ No Condition: ��,L <br /> Does side sewer have at ieast 1°/a slope irom ihe building to sevaer m2in? Q Yes ❑ No Describe: <br /> Have all building se�ver drain connections to the side se�ver been identified and iocated? �Yes ❑ No <br /> Have all property slorm drainage connections to ihe side sewer been identified and located? �Yes ❑ No <br /> Has properly been evaluated for drainage deficiencies with findings communicated to prorerty owncr? X❑Yes ❑ No <br /> Installation Details: (� <br /> What type and brand of 8WD was installed at lhis sile(Clean Check BWV, Grinder pump,etc.):�_�c__ �ix <br /> VVhere was lhe device installed(general descriplion,allach map)? �'e Q2�!'t('y��� I�C.e a� <br /> Was ihere any other sewer or storm drainaye�vork completed in conjunclion tivith the�WD�vork? Is so please describe:_ <br /> �y�0 <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream oi ihe BbVD? �1'es ❑No Commenis: <br /> Does BWD positioning meets minimum slope requiremenl of>1%? �� Yes ❑No Comments: <br /> Can BWD be pulled out(or inspection and maintenance after loosening Ihumb screw? [�Yes ❑No <br /> Is BWD locked into the proper posilion and ii.�rnb screw tightened? � Yes ❑No <br /> Circle the BWD co e : irrigalion cou �dseape area)I traffic load bearing cover(drive suriacej/access hatch (builtling) <br /> Was property owner s own Ihe localion o(Ihe installed BWD? �]Yes ❑ No Comments: <br /> Property Owner s Signature: � . -�l f��� Date:� Y o2U �J <br /> Inslaller's Signature: il Date: <br /> Revision:2 1 Friday,Septembcr 12, 2014 <br />